on Thursday, 25 October 2018.

This posting coincides with the 40th Anniversary of the 1978 Alma Ata
Declaration on Health for All. Please read and comment.

I have just arrived at Astana, Kazakhstan for the 40th Anniversary of the “Health for All Declaration” and the Global Conference on Primary Health Care (PHC) 25 – 26 October, 2018. It presents an opportunity for us to reflect on how we will monitor PHC especially
its contribution to our progress towards achievement of health for all, UHC and SDGs.

Let us start by drawing attention to the fact that among the current SDG indicators on UHC, there is no indicator that explicitly monitors household and community participation and action for health. Yet we know that the demand side of UHC is critical for supporting health
promotion, wellbeing and building societies that enable healthy lifestyles, and for influencing the habits of individuals and the behavior of institutions.
The demand side facilitates effective engagement of the people and the community in building strong, resilient and responsive health systems.

This population ownership and engagement cannot be optional because the Declaration state that people have a duty and a right to full participation in influencing their own health and health care.

We know that achieving health outcomes and designing effective health services delivery programs at country level are constantly faced with the challenge of getting the right balance between health promotion and disease prevention on the one hand and treatment of diseases on the other. At the World Health Summit (WHS) in Berlin, 14 – 16
October, 2018 questions were still being asked whether UHC was about providing
health care and not about ensuring the enjoyment of holistic health as
defined in the constitutions of WHO and the Universal Declaration of
Human Rights.

There were similar debates during the 71st World Health Assembly in May, 2018, on what the face of our effort on SDGs and UHC ought to look like. Will it be actions to promote healthy living so as to ensure that people do not lose their existing inborn health and that they delay
the need for health care for as long as possible? Will it be health financing and
health insurance for accessing services to treat illness and diseases?


At the WHO Afro Regional Committee in August, 2018 statements by several Health Ministers suggested that establishing National Health Insurance schemes is all that they needed to do to achieve UHC.


This is a matter for concern particularly when Dr. Tedros the Director General of WHO frequently states that “all roads lead to UHC.” The “Global Action Plan for healthy lives and well-being for all” was launched by WHO and eight partner health institutions at the Berlin
WHS where, among others, Dr Tedros stated that “health is made and sustained by families” in their homes and communities.


Surely the face of our effort to achieve SDGs and UHC will need to be the visibility and success on both. The WHO definition of UHC states: “Universal health coverage (UHC) means that all people and communities can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship”. This language is balanced and addresses health promotion, disease prevention and treatment of illness and the need for financing. The framing of the UHC definition implies that a public health approach
precedes the medical interventions. This is smartly captured in the language of SDG 3; stated as “Ensure healthy lives and promote wellbeing for all at all ages”.



Monitoring and measurement of progress in SDGs and UHC is needed in order to guide, motivate and ensure action, results and accountability at all levels. There is currently one SDG Target and two indicators on UHC as follows:

Target 3.8 “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all” There are two indicators to monitor this target:

Indicator 3.8.1 “Coverage of essential health services (defined as the average coverage of essential services based on tracer interventions that include reproductive, maternal, newborn and child health, infectious diseases, non-communicable diseases and service capacity and access, among the general and the most disadvantaged population)”.

Indicator 3.8.2 is “Proportion of population with large household expenditures on health as a share of total household expenditure or income”. This indicator will measure the cost of treatment of illness and diseases.

The indicator 3.8.2 on household expenditure for access to services for treatment of diseases and other medical interventions including vaccinations for disease prevention is explicit and will monitor the financial implications of UHC to households. However, indicator 3.8.1 is not explicit in calling for specific monitoring and measurement of household and community behavior and actions that enable healthy people to remain healthy through their own participation. Such an
indicator would respond to the call for “all people and communities can use the promotive, preventive services” in the definition of UHC.

The framers of these indicators have fallen into the usual trap in health system design; namely that the pressures to society and governments to pay more attention to repairing and restoring lost and broken individual and community health are stronger than those aimed
to promote, sustain and protect existing health. The drama of providing urgent health care to restore damaged individual and community health is easily the more visible face of the health system and accordingly receives more attention and more resources than health
promotion that focuses on important health needs that may not be immediately visible and do not demand immediate action. Getting the balance right is a challenge to all health systems and will be helped by having an explicit and specific UHC indicator that monitors and
measures health action by households and communities.

A call for correction of this important omission of an explicit indicator on health promotion through community participation has also been published by the BMJ signed by a number of promoters and can be accessed at

SDG targets and indicators are regularly reviewed and the next review will take place in 2020. We therefore call for the inclusion of at least one explicit target and indicator on community participation in health promotion and well-being in the official UN SDG Indicator
Classification. The process for this should be taken up urgently, and should be led by Member States, Civil Society and the WHO.

I welcome your suggestions and comments.



Comments (5)

  • Eunice Brookman-Amissah

    Eunice Brookman-Amissah

    25 October 2018 at 08:50 |
    Dear Francis,

    Greetings from Nairobi where I am still domiciled following my retirement from Ipas in 2014. It is the lush golf courses and lovely weather that are still keeping me here.!J

    And thank you for your regular posts which I find very pertinent and relevant as well as very useful and informative. Most importantly they are thought provoking and challenging!.

    I agree with you entirely about the missing moitie of indicator 3.8.1 for specific monitoring and measurement of household and community behavior and actions that enable people to
    remain healthy through their own participation.

    I was reviewing documents just a couple of weeks ago while preparing a paper for delivery at the just ended FIGO world congress in Rio and I reviewed SDG Target 3.8 and noted the
    shortcoming in the indicators you have just outlined so succinctly.

    And last year I was invited to make the keynote address in the 8th of a series of twelve monthly Symposia –“Achimota Speaks” (see attached) to mark the 90th anniversary of the founding
    of our great Alma Mata- Achimota School- which was purposely built to “train and groom leaders for Africa” and which has produced great leaders like Kwame Nkrumah, Sir Dawda Jawara of
    the Gambia, Hastings Kamuzu Banda of Malawi among others as well as Ghana’s second President Edward Akuffo-Addo and his illustrious wife and parents of current president Nana Akuffo-
    Addo. Also Presidents Rawlings, and John Atta-Mills to name a few.


    I believe the expectation was for me to extol the virtues of the high-rise multi-million dollar hospitals with state of the art equipment and designer doctors and health staff. But my
    background and experience as well as personal belief in “Preventive and Promotive” Medicine and PHC made me to veer the symposium in the direction that I felt was more realistic.

    I made strong points for Preventive health and Health Promotion as being the bedrock and indeed the sine quae non for any successful health delivery system.
    I have attached my paper here for your information and comments. And to share on the platform if you deem it appropriate.

    Sadly while the gutters in the capital, Accra, are full of filthy muck and stagnant water and while people still don’t have potable water or safe toilets and while children especially
    but also adults are malnourished and live unhealthy life styles we are resorting to multimillion dollar turn key hospital projects that only serve to line the pockets of politicians and
    others who handle the contracts for these. Currently we have three such humongous and extremely costly structures with NO idea as to how to set about using them. we don’t have the staff
    or expertise. Very sad indeed.

    So yes indeed we need to continue to make the case for Preventive and Promotive health and Community Medicine --which is what it was called in my time in Medical School. (And BTW I got
    a distinction in Community Medicine - before it came to be called Public Health). We need to proceed with full involvement of the People.

    So how do we get our leaders and especially our Ministers of Health to embrace Preventive and Promotive Health Care in addition to the other more lucrative areas of Health Service?
    Buying drugs and equipment and supplies is definitely more "interesting;!J

    Best Regards to you! And enjoy your stay in Astana!


    Ambassador Dr. Eunice Brookman-Amissah
    Special Advisor to the Ipas President for African Affairs
    • Francis Omaswa

      Francis Omaswa

      25 October 2018 at 08:52 |
      Dear Eunice,

      This is a great comment and thank you for the attachments. You have passionately illuminated the subject.
      What will you do now? Ghana is one of the sponsors of the Global Action Plan that was launched in Berlin. Can the President and government of Ghana join others in leading the review of the Indicators in 2020 or during the September 2019 UN Summit on UHC and in between including the WHO Executive Board and the WHA?

  • Dr. Asuman Lukwago

    Dr. Asuman Lukwago

    25 October 2018 at 11:22 |
    Thanks Francis and Eunice,
    I can only contribute two observations :
    1- That majority of people are HEALTHY before they become SICK /ILL. Though some are born with diseases or genetically vulnerable get diseases as they live on earth, but these are minority groups in all Global communities. E.g Albinos are more predisposed to skin cancers. Of course humans are mobile, therefore are can collide with other mobile agents resulting into traumatic morbid entities.etc

    Therefore the critical Health interventions should aim at informing/supporting people to remain Healthy, and to be prepared to treat those who drift to the SICK bracket. Countries need both preventive /promotive services (primary,) and Medical services ( secondary, tertiary levels of prevention)
    2- The SDGS are a set of Global strategic agenda, and as such member states are supposed to cascade this agenda into their country strategies. For example at a Global level the indicator targets may appear as ALL CHILDREN should be immunised, and at a country level the words ALL CHILDREN should be numerically known based on specific population data. Member states should as much as possible customise the SDGS in their country strategic planning.

    Dr. Asuman Lukwago
    Permanent Secretary of the Education service commission. Uganda.
  • Prof Lovemore Gwanzura

    Prof Lovemore Gwanzura

    26 October 2018 at 15:23 |
    Hi Francis!

    I gather we are all healthy until we are ill. Illness comes because you have failed to prevent the onset of diseases through luxury living ( NCD) due to poverty due to lack of proper nutrition etc and thus exposure to infectious diseases. This status is some instances is caused by the health systems faulting or just collapsing due to political, social or economical pressures. Thus Critical health interventions or strategies must aim known causal issues ( researched-evidence based) rather than Associated related issues. This is how indicator targets must be identified rather than generalization as currently done by WHO etc

    God willing we shall find funds to doing this before embarking on health promotions for universal coverage. Enjoy your Asian visit Francis.

    Lovemore Gwanzura Bsc. Mphil MD . Mmedclinepi. PHD. ZAS fellow
    Professor CHSC,University of Zimbabwe
    Lab Director BRTI
  • Anthony Mbonye

    Anthony Mbonye

    29 October 2018 at 07:01 |
    Dear All
    The debate on UHC is very interesting. Prof Omaswa flags off an important issue on the involvement of households in achieving UHC targets. Several indicators like Antenatal care attendance, deliveries at health facilities, immunisation of children have a big component of household involvement and action. Other variables to consider are: proportion of children stunted, hand washing practices and availability of hand washing facilities. Apart from the last one, all mentioned variables are captured in the Demographic and Health Surveys (DHS).
    I am interested in hearing more suggestions so that we can identify the most suitable indicators.



    Prof. Anthony K Mbonye
    MBCHB, Dip.C.Sc, MA, MPH, PhD, FRCP (UK).
    Professor of Maternal Health; Specialist in Malaria and Infectious Diseases Control, School of Public Health, College of Health Sciences, Makerere University; P.O Box 7072 Kampala, Uganda, Tel. +256 772411668.

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